The use of sentinel node biopsy in breast cancer patients undergoing skin sparing mastectomy and immediate autologous reconstruction.
ABSTRACT Intraoperative frozen section examination of the sentinel node in breast cancer patients is associated with a high number of incorrect negative results with the sentinel node becoming positive in the permanent examination and necessitating a secondary axillary lymph node dissection. A reoperation of the axilla following skin-sparing mastectomy and immediate autologous tissue reconstruction may compromise the vascular pedicle of the flap and should be avoided.
Eighty breast cancer patients underwent skin-sparing mastectomy with immediate autologous reconstruction and sentinel node biopsy followed by axillary lymph node dissection irrespective of the result of the frozen section of the sentinel node. The goal of the study was to identify a subgroup of patients with incorrect negative sentinel node(s) in the frozen section who may forego a secondary axillary lymph node dissection due to a low risk of positive nonsentinel nodes.
Frozen section examination of the sentinel node was negative in 58 patients and positive in 22 patients. Permanent histologic examination revealed tumor in 13 of 58 (22.4 percent) sentinel node(s) found negative in the frozen section. None of these 13 patients showed positive nodes in the axillary specimen, whereas nine of 22 patients with their metastases in the sentinel node found through intraoperative frozen section examination had additional positive nonsentinel node(s) (p = 0.001).
Patients with incorrect negative sentinel node(s) found in the frozen section examination had a significantly decreased risk for additional positive nonsentinel node(s) compared with patients with sentinel node metastases found in the frozen section. However, to avoid a secondary axillary lymph node dissection, the authors suggest performing sentinel node biopsy before mastectomy under local anesthesia to have the permanent result of the sentinel node available before a planned reconstruction.
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ABSTRACT: This retrospective study was designed to provide a preliminary outcome analysis in patients with positive sentinel nodes who declined axillary dissection. A review was conducted of patients who underwent lumpectomy and sentinel lymph node excision for invasive disease between January 1998 and July 2000. Those who were found to have sentinel lymph node metastasis without completion axillary dissection were selected for evaluation. Follow-up included physical examination and mammography. Thirty-one patients were identified who met inclusion criteria. Primary invasive cell types included infiltrating ductal carcinoma, infiltrating lobular carcinoma, and mixed cellularity. Most primary tumors were T1. Nodal metastases were identified by hematoxylin and eosin stain and immunohistochemistry. Twenty-seven of the metastases were microscopic (<2 mm), and the remaining four were macroscopic. All patients received adjuvant systemic therapy. With a mean follow-up of 30 months, there have been no patients with axillary recurrence on physical examination or mammographic evaluation. We have presented patients with sentinel lymph nodes involved by cancer who did not undergo further axillary resection and remain free of disease at least 1 year later. This preliminary analysis supports the inclusion of patients with subclinical axillary disease in trials that randomize to observation alone.Annals of Surgical Oncology 03/2003; 10(2):126-30. · 4.12 Impact Factor
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ABSTRACT: To the authors' knowledge it has not yet been determined which patients with primary breast carcinoma and an axillary sentinel lymph node (SN) metastasis have additional metastases in nonsentinel lymph nodes. Pathologic features of the primary breast carcinoma and its SN metastasis were examined in 194 patients and correlated with the tumor status of the non-SNs in the same axillary basin. Two-level cytokeratin immunohistochemistry was applied to the SNs and to non-SNs of cases that were negative by standard hematoxylin and eosin examination. Lymph node staging based on SN findings, size of the primary tumor, and presence of peritumoral lymphatic vascular invasion (LVI) were associated with non-SN metastasis. The majority (63%) of the 101 patients with SN macrometastases had non-SN metastases. Extranodal hilar tissue invasion in conjunction with SN involvement also was strongly associated with non-SN metastasis (P = 0.0001) but was present in only 65% of patients (35 of 54 patients) with non-SN macrometastases. Approximately 26% of patients (24 of 93 patients) with SN micrometastases (</= 2.0 mm) had non-SN metastases; among these patients only primary tumor size and peritumoral LVI were correlated with non-SN metastasis. Detailed pathologic examination of the primary tumor and its SN metastasis may increase precision in the selection of patients for further axillary surgery or radiation therapy.Cancer 08/2000; 89(3):574-81. · 5.20 Impact Factor
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ABSTRACT: Skin-sparing mastectomy has been advocated as an oncologically safe approach for the management of patients with early-stage breast cancer that minimizes deformity and improves cosmesis through preservation of the skin envelope of the breast. Because chest wall skin is the most frequent site of local failure after mastectomy, concerns have been raised that inadequate skin excision could result in an increased risk of local recurrence. Precise borders of the skin resection have not been well established, and long-term local recurrence rates after skin-sparing mastectomy are not known. The purpose of this study was to evaluate the oncologic safety and aesthetic results for skin-sparing mastectomy and immediate breast reconstruction with a latissimus dorsi myocutaneous flap and saline breast prosthesis. Fifty-one patients with early-stage breast cancer (26 with ductal carcinoma in situ and 25 with invasive carcinoma) undergoing primary mastectomy and immediate reconstruction with a latissimus flap were studied from 1991 through 1994. For 32 consecutive patients, skin-sparing mastectomy was defined as a 5-mm margin of skin designed around the border of the nipple-areolar complex. After the mastectomy, biopsies were obtained from the remaining native skin flap edges. Patients were followed for 44.8 months. Histologic examination of 114 native skin flap biopsy specimens failed to demonstrate breast ducts in the dermis of any of the 32 consecutive patients studied. One of 26 patients with ductal carcinoma in situ had metastases to the skin of the lateral chest wall and back. Four other patients, one with stage I disease and three with stage II-B disease, had recurrent breast carcinoma. The stage I patient had a local recurrence in the subcutaneous tissues near the mastectomy specimen. Two patients suffered axillary relapse, and one had distant metastases to the spine. The findings of this study support the technique of skin-sparing mastectomy as an oncologically safe one, based on an absence of breast ductal epithelium at the margins of the native skin flaps and a local recurrence rate of 2 percent after 45 months of follow-up. Although these results need to be confirmed with greater numbers of patients and longer follow-up, skin-sparing mastectomy and immediate breast reconstruction may be considered an excellent alternative treatment to breast conservation for patients with ductal carcinoma in situ and early-stage invasive breast cancer.Plastic & Reconstructive Surgery 08/1998; 102(1):49-62. · 3.54 Impact Factor